FAQ Directory: Health Plan Accreditation

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11.15.2017 Delegation of NET Directories How is NET 7, Element E, factor 1 scored when an organization delegates only the directory functions in NET 6?

The organization is scored NA for factor 1 because the physician and hospital directories do not involve network management procedures.
 

HP 2018

11.15.2017 The Value-based Payment worksheet What is the Value-Based Payment worksheet for PHM 3B, and where can we find it?

The Value-Based Payment worksheet gives instructions on required reporting to satisfy element PHM 3B: Value-Based Payment Arrangements. It is a workbook that must be completed as part of the survey tool.

HP 2018

11.15.2017 Updated: Timeliness of postservice appeal decisions for Medicare and Medicaid Does the recent change for Medicare and Medicaid postservice appeals from 60 calendar days to 30 calendar days align with Chapter 13 of the Medicare Managed Care Manual?

No. Medicare product lines continue to follow the 60-calendar-day time frame for postservice appeals.

Note: The requirement is correct for Medicare product lines; Medicaid product lines continue to follow the 30-calendar-day time frame for postservice appeals.

HP 2018

11.15.2017 DEA or CDS Certificates Is a photocopy of a practitioner's DEA certificate acceptable documentation for CR 3, Element A, factor 2?

Yes. Although photocopies are generally not acceptable documentation for verifying credentialing information, they are accepted for DEA certification because the DEA does not provide phone or written verification.

HP 2018

9.15.2017 Utilization Management and Use of Voicemail When does voicemail meet UM notification requirements?

Voicemail meets UM requirements only when the organization notifies a practitioner about the opportunity to discuss a denial decision. The organization must document who left the message, along with the date and time it was left. Voicemail messages do not meet any other notification requirement.

HP 2018

9.15.2017 Complex Case Management When does the time frame for completing the initial assessment for complex case management begin?

The time frame for completing the initial assessment begins when the member is determined to be eligible for complex case management. A member is eligible once identified using criteria from Element B, factor 2 and data sources in Element C (e.g., claims/encounter data, hospital discharge data). The initial assessment is not used to determine eligibility, although information gathered in the assessment may make a member ineligible.

Note: There is no “opt-in” option for identifying members.
 

HP 2017

9.15.2017 Appeals covered in QI 4, Element C What types of appeals are included in QI 4, Element C: Coverage Appeals (e.g., in UM 8-UM 9) or noncoverage appeals (e.g., in RR 2)?

QI 4 requires organizations to collect data from all sources of member complaints and appeals. This includes UM coverage appeals addressed in UM 8-UM 9 and noncoverage appeals addressed in RR 2.
 

Note: Data collected and analyzed prior to December 15, 2017,will be accepted as meeting the requirement, even if not all types of appeals are included. Data collected and analyzed on or after this date must comply with the requirement stated in the FAQ.

If your organization collected and analyzed data prior to December 15, 2017, and interpreted the requirement as applying to only one type of appeal, notify the surveyor at the start of the survey so the misinterpretation does not affect scoring.

 

HP 2018

9.15.2017 Denial Notices—Right to Representation The denial notification must include a statement that members may be represented by anyone they choose, including an attorney. If the notification states that members have the right to be represented by anyone, but does not specify “including an attorney,” is this acceptable?

Yes. If the notification indicates that members may be represented by anyone, this is acceptable because the reference to “anyone” implies “including an attorney.” If the notification lists specific types of individuals, it must also specify “an attorney.”

HP 2018

8.15.2017 Overturned appeals Who can overturn a medical necessity or benefit denial on appeal?

NCQA allows any individual at the organization to overturn a denial on appeal. Upheld denials still require same-or-similar specialist review for medical necessity decisions and review by a nonsubordinate for benefit decisions.

HP 2018

5.15.2017 Updated: Pharmacists as Same-or-Similar Specialists May pharmacists be considered “same-or-similar” specialists?

No. Beginning with files processed on and after February 1, 2017, pharmacists are not considered same-or-similar specialists because they do not treat patients in most instances.
Note: An FAQ communicating that pharmacists are not considered same-or-similar specialists was posted on October 15, 2016, and this policy was applied beginning February 1, 2017 (90 days from notification).

HP 2017

5.15.2017 QI 5 Element G: Complex Case Management Assessment and Evaluation Is collecting information or data only for each factor sufficient to meet the “assessment” or “evaluation” requirements in QI 5, Element G (QI 9, Element G in MBHO)?

No. Presenting data alone is not sufficient. The case manager must draw a conclusion from the data and note it in the member’s file.

Note: Effective for complex case management files that were opened on or after September 1, 2017.

HP 2017

4.15.2017 UM 9B: Timeliness of the Appeal Process for Medicaid Under the new Medicaid Managed Care Final Rule, effective July 1, 2017, Medicaid organizations are required to have only one level of appeal. However, this may not be effective immediately for organizations with contracts prior to this date. How will NCQA evaluate Medicaid organizations coming through under the 2017 standards and guidelines?

Organizations with one level of appeal will be evaluated against the timeliness requirements specified in the current 2017 standard. Medicaid organizations that maintain a two-level appeal process will be evaluated under the 2016 standard requirements; these time frames apply:

  • For preservice first-level appeals: 30 calendar days.
  • For postservice first-level appeals: 60 calendar days.

HP 2017